Cost-effectiveness of alternative interventions for the prevention and treatment of coronary heart disease

The Victorian Active Script Programme: promising signs for general practitioners, population health, and the promotion of physical activity

BACKGROUND

The Active Script Programme (ASP) aimed to increase the number of general practitioners (GPs) in Victoria, Australia who deliver appropriate, consistent, and effective advice on physical activity to patients. To maximise GP participation, a capacity building strategy within Divisions of General Practice (DGPs) was used. The objectives of the programme were to (a) train and support GPs in advising sedentary patients, and (b) develop tools and resources to assist GPs.

OBJECTIVE

To evaluate the effectiveness of the ASP.

METHODS

A systems approach was used to promote capacity in Victorian general practice. Economic analyses were incorporated into the programme's evaluation. Participants were selected DGPs and their GP members. The programme worked with DGPs to train GPs and provide relevant resources. The main outcome measures were (a) changes in GP knowledge and behaviour and (b) cost effectiveness, based on modelled estimates of numbers of patients advised and adopting physical activity and gaining the associated health benefits.

RESULTS

GP awareness and provision of physical activity advice increased. Although the programme's reach was modest, based on actual GP involvement, the cost effectiveness figures (138 Australian dollars per patient to become sufficiently active to gain health benefits, and 3647 Australian dollars per disability adjusted life year saved) are persuasive.

CONCLUSIONS

The ASP increased DGPs' capacity to support GPs to promote physical activity. There is a strong economic argument for governments to invest in such programmes. However, caution is warranted about the maintenance of patients' activity levels. Programme refinement to encourage GPs to use community supports more effectively will guide future development. Further research on long term patient adherence through a multisectorial approach is warranted.

Projecting coronary heart disease incidence and cost in Australia: results from the incidence module of the Cardiovascular Disease Policy Model

OBJECTIVE

To project the incidence rates of coronary heart disease and the number of hospitalised incident coronary heart disease cases and hospital costs associated with the first hospital admission, for males and females aged 45-69, up to 2014 in Australia.

METHOD

A computer simulation model using a microsimulation technique was developed to simulate individuals' coronary heart disease history over time for a sampled Australian population characterised by major coronary risk factors. Using the simulated incidence rates, population and hospital cost data, the number of hospitalised incident coronary heart disease events and hospital costs associated with the first hospital admission were projected.

RESULTS AND CONCLUSIONS

If current cohort-specific coronary risk factor distributions change only by a location shift and the availability and efficacy of current treatment patterns prevail, the model projects declines of 13% and 24% in incidence rates for males and females aged 45-69 respectively by 2014. However, because the population aged 45-69 is projected to increase over the same period, the number of projected hospitalised coronary heart disease events and the hospital costs associated with the first admission will increase by more than 40%.

IMPLICATIONS

A modeling strategy which integrates information on coronary risk factor distributions, epidemiologic, demographic and economic data can provide comprehensive projections that assist future health care planning in the area of coronary heart disease.

Economic evaluation of health promotion: friend or foe?

It is commonly believed that economic evaluation is hostile to health promotion and that the requirement for health programs to be cost effective will result in a biased allocation of funds in favour of programs that can demonstrate short-run benefits as defined by inadequate outcome measures. The paper is concerned with the validity of this perception. It is argued that economic evaluation has the potential for treating health promotion activities on an equal basis with other health interventions. The major obstacle to this does not arise from the theory of economic evaluation, which is discussed, but from a lack of information about outcomes. Without this information any evaluation--economic or otherwise--is flawed. Three problems relating to the economic evaluation of health promotion activities are considered. These are: the discounting of future health benefits; the potential for economic evaluation to be counter-productive if applied to 'immature' projects; and the practical problems encountered in the measurement of the outcomes of health promotion programs. A four-fold classification which is based upon a distinction between disease cure, individual health promotion, community welfare and systemic change designed to promote either individual health or social well-being. The capacity of economics to incorporate these objectives is discussed.

An evaluation of a primary preventive dental programme in non-fluoridated areas of Victoria, Australia

A primary preventive dental programme targeting adolescents living in non-fluoridated areas of Victoria, Australia was evaluated for a three-year period. The programme comprised annual placement or replacement/repair of fissure sealants combined with a weekly 0.2 per cent sodium fluoride mouthrinse and was evaluated in terms of acceptance by the providers and the community to which it was directed. Acceptance was measured using accessibility, availability, continuity, quality of care, role responsibility, provider and consumer satisfaction, and cost-effectiveness. In general, the programme was considered to represent an acceptable model for future preventive interventions, although there were areas of its design that were found to require improvement. In particular, deficiencies in the manner in which the fluoride mouthrinsing component was delivered indicate that further investigation would be required before a recommendation to adopt its use could be made.

The cost-effectiveness of a cardiovascular risk reduction program in general practice

An economic evaluation was conducted alongside a randomised controlled trial of two lifestyle interventions and a routine care (control) group to assess the cost-effectiveness of a general practice-based lifestyle change program for patients with risk factors for cardiovascular disease. Routine care was the base case comparator because it represents 'current therapy' for cardiovascular disease (CVD). A 'no care' control group was not considered a clinically acceptable alternative to lifestyle interventions. The interventions consisted of an education guide and video for GPs to assess individual patient risk factors and plan a program for risk factor behavior change. Each patient received a risk factor assessment, education materials, a series of videos to watch on lifestyle behaviors and some patients received a self-help booklet. Eighty-two general practitioners were randomised from 75 general practices in Sydney's Western Metropolitan Region to (i) routine care (n = 25), (ii) video group (n = 29) or (iii) video + self help group (n = 28). GPs enrolled patients into the trial who met selection criteria for being at risk of CVD. There were 255 patients in the routine care (control) group, 270 in the video (intervention) group and 232 in the video + self help (intervention) group enrolled in the trial. Outcome measures included patient risk factor status: blood pressure, body mass index, cholesterol and smoking status at entry to trial and after 1 year. Changes in risk factors were used to estimate quality adjusted life years (QALYs) gained. One hundred and thirty patients in the routine care group, 199 in the video group and 155 in the video + self help group remained in the trial at the 12-month review and had complete data. The cost per QALY for males ranged from $AUD152,000 to 204,000. Further analysis suggests that a program targeted at 'high risk' males would cost approximately $30,000 per QALY. The lifestyle interventions had no significant effect on cardiovascular risk factors when compared to routine patient care. There remains insufficient evidence that lifestyle programs conducted in general practices are effective. Resources for general practice-based lifestyle programs may be better spent on high risk patients who are contemplating changes in risk factor behaviours.